EVALUATION OF RECONSTRUCTION IN KASR EL-AINY HOSPITAL IN THE LAST 5 YEARS By

Laila Ahmed Lotfy Aboul Nasr M.B.B.Ch . Faculty Of Medicine, Cairo University

A thesis Submitted in Partial Fulfillment of master Degree in General surgery

Supervisors Prof Dr. Ahmed Gameel El Sharkawy Prof. of General & Plastic Surgery Faculty of Medicine Cairo University

Prof Dr. Ahmed Adel Nour El Din Prof. of General & Plastic Surgery Faculty of Medicine Cairo University

Assistant Prof Dr. Hatem Helmy Zaky Assistant Prof. of General & Plastic Surgery Faculty of Medicine Cairo University

2012 ACKNOWLEDGEMENT

∑ First of all I would like to thank ALLAH, who granted me everything good in my life. ∑ I would like to thank Prof. Dr. Ahmed ElEl----SharkawySharkawy , who has always been a big support to me. ∑ All my gratitude to Prof. Dr. Ahmed Adel Nour ElEl---- Din , who helped me all through the construction of this work. ∑ Special thanks to Prof. Dr. Hatim Helmi for his great contribution in this thesis. ∑ I would like to dedicate this work to my family who always supported and encouraged me all through the years. ∑ Finally I have to pay great respect to my beloved husband for pushing me always forwards.

DEDICATION

To my Beloved Family Abstract

The breast is a very important organ for the woman's self-esteem. After loosing it in cases of mastectomy for breast cancer the woman is psychologically down. From this point breast reconstruction has gained its importance. There are several methods to reconstruct the breast, either by prosthetic techniques using expanders and implants or by autologous techniques using different kinds of flaps.

The flaps are either pedicled as the latismusdorsi and the transversus rectus abdominusmyocutaneous (TRAM) flap, free flaps as the free TRAM and the gluteal flaps,or perforator based flaps as the deep and superficial inferior epigastric perforator flaps.

Key words :

Evaluation of Breast - female breast - Breast Cancer .

CONTENTS

Page

REVIEW OF LITERATURE

Anatomy of the female breast 1

Pathology and Classifications of Breast Cancer 15

Surgical Treatment Of Breast Cancer 27

Options Of Breast Reconstruction Following Mastectomy 44

MATERIALS AND METHODS 118

RESULTS 125

DISCUSSION AND CONCLUSION 133

SUMMARY 139

REFERENCES 140

ARABIC SUMMARY

i LIST OF FIGURES

No. Title Page

Fig. (1) (Introduction to the body,2001). 3

Fig. (2) (Introduction to the human body,2001). 6

Fig. (3) (Introduction to the human body,2001). 8

Fig. (4) (Introduction to the human body,2001). 9

Fig. (5) (Introduction to the human body,2001). 10

Fig. (6) (Gray's Anatomy of the human body,1918) 12

Fig. (7) (Essentials of breast surgery,2009). 28

Fig. (8) (Essentials of breast surgery,2009). 33

Fig. (9) (Oncoplastic Breast Surgery,2010) 41

Fig. (10) (Oncoplastic Breast Surgery,2010) 41

Fig. (11) (Oncoplastic breast surgery,2010) 46

Fig. (12) (Oncoplastic breast surgery,2010) 48

Fig. (13) (Plastic & reconstructive surgery of the breast ,2009) 51

Fig. (14) (Plastic & reconstructive surgery of the breast ,2009) 52

Fig. (15) (Plastic & reconstructive surgery of the breast ,2009) 52

Fig. (16) (Plastic & reconstructive surgery of the breast ,2009) 53

Fig. (17) (Oncoplastic breast surgery,2010) 54

Fig. (18) (Plastic & reconstructive surgery of the breast ,2009) 57

Fig. (19) (Plastic & reconstructive surgery of the breast ,2009) 58

Fig. (20) (Plastic & reconstructive surgery of the breast ,2009) 60

ii No. Title Page

Fig. (21) (Plastic & reconstructive surgery of the breast ,2009) 66

Fig. (22) (Mathes SJ, Nahai F,1981) 69

Fig. (23) (Gray's Anatomy of the Human Body,1918) 73

Fig. (24) (Plastic & reconstructive surgery of the breast ,2009) 74

Fig. (25) (Plastic & reconstructive surgery of the breast ,2009) 78

Fig. (26) (Plastic & reconstructive surgery of the breast ,2009) 80

Fig. (27) (Plastic & reconstructive surgery of the breast ,2009) 82

Fig. (28) (Gray's Anatomy of the Human Body,1918) 83

Fig. (29) (Plastic & reconstructive surgery of the breast ,2009) 84

Fig. (30) (Plastic & reconstructive surgery of the breast ,2009) 84

Fig. (31) (Shestak KC,2006) 86

Fig. (32) (Shestak KC,2006) 86

Fig. (33) (Plastic & reconstructive surgery of the breast ,2009) 89

Fig. (34) (AschermanJA, et al, 2008) 90

Fig. (35) (Shestak KC,2006) 91

Fig. (36) (Plastic & reconstructive surgery of the breast ,2009) 95

Fig. (37) (Plastic & reconstructive surgery of the breast ,2009) 96

Fig. (38) ( RozenWM, et al, 2008) 100

Fig. (39) (Craigie JE,et al,2003) 102

iii No. Title Page

Fig. (40) Before and after bilateral mastectomy for ductal 102 carcinoma in situ (DCIS) with immediate deep inferior epigastric perforator (DIEP) flap reconstruction.(Craigie JE, et al, 2003)

Fig. (41) (Della CroceFJ, et al, 2011) 103

Fig. (42) (Grabb's Encyclopedia of Flaps,2008) 104

Fig. (43) (Della Croce FJ, Sullivan SK,2005) 106

Fig. (44) ( Bogue DP,2003) 111

Fig. (45) (American Cancer Society,2009) 113

Fig. (46) (American Cancer Society,2009) 114

Fig. (47) (American Cancer Society,2009) 114

Fig. (48) (American Cancer Society,2009) 115

Fig. (49) (American Cancer Society,2009) 116

Fig. (50) (Question 1) 125

Fig. (51) (Staging) 126

Fig. (52) (Number of cases) 127

Fig. (53) (Patients age) 128

Fig. (54) (Technique) 129

Fig. (55) (causes of preference) 130

Fig. (56) (Complications) 131

Fig. (57) ( and reconstruction) 132

iv ------Review of Literature

REVIEW OF LITERATURE

Anatomy of the female breast

The adult female breast or lies in the subcutaneous tissue (superficial fascia) of the anterior thoracic wall.The base extends from the sternal edge to near the midaxillary line, and from the second to the sixth ribs in the nonptotic state.

The breast overlies pectoralis major,serratus anterior and a small part of the rectus sheath and external oblique muscle (Last’s Anatomy,2006).

A small part of the upper outer quadrant extends into the and lies in the subcutaneous fat, called the axillary tail.

Both men and women develop from the same embryological tissues. However, at puberty, female sex hormones, mainly estrogen, promote which does not occur in men due to the higher level of testosterone. As a result, women's breasts become far more prominent than those of men . (Last’s Anatomy,2006).

Anatomically, the mammary gland is a cone with the base at the chest wall, and the apex at the nipple. The superficial layer (superficial fascia) is separated from the by 0.5–2.5 cm of subcutaneous fat (adipose tissue).The suspensory ligaments (Cooper's ligaments) are prolongations of fibrous tissue that radiate from the superficial fascia to the skin .(Last's Anatomy,2006).

The breasts are apocrine glands that produce milk for the feeding of infant children. Each breast has a nipple surrounded by an areola

1 ------Review of Literature

(nipple-areolacomplex, NAC), the skin color of which varies from pink to dark brown, and has sebaceous glands. Besides milk glands, the breast is composed of connective tissue (collagen, elastin), adipose tissue (white fat), and the suspensory Cooper's ligaments.The adult breast contains 14– 18 irregular lactiferous lobes that converge to the nipple through ducts 2.0–4.5 mm in diameter; in each breast, 4 –18 lactiferous ducts drain to the nipple; the glands-to-fat ratio is 2:1 in lactating women, and 1:1 in non-lactating women. (Introduction to the human body,2001 )

The milk ducts (lactiferous ducts) are immediately surrounded with dense connective tissue that functions as a supporting framework. The glandular tissue of the breast is biochemically supported with estrogen; thus, when a woman reaches menopause and her estrogen levels decrease, the glandular tissue then atrophies, withers, and disappears, leaving a breast composed only of fat (adipose tissue), superficial fascia, the suspensory ligaments, and the skin envelope. The structural support system of the breast is made of superficial fascia ; the suspensory ligaments and the skin envelope can change the fibrous frame with age and the force of Earthly gravity . (Ramsay DT et al,2005).

The dimensions and the weight of the breast vary much among women: 500–1,000 gm each. A small-to-medium-sized breast weighs 500 gm or less; large breasts weigh 750 –1,000 gm. The tissue composition ratios of the breast vary from woman to woman; some breasts have greater proportions of glandular tissue than of adipose or connective tissues, and vice versa; and it is the fat-to-connective-tissue ratio that determines the firmness, the density, of the breast. In the course of a woman’s life, her breasts will change size, shape, and weight, because of the bodily changes occurred in thelarche, menstruation, pregnancy, the

2 ------Review of Literature weaning of an infant child, and the climacterium .(Essentials of breast surgery,2009).

Fig. (1) (Introduction to the human body,2001 ).

The Breast: Cross-section scheme of the mammary gland:

1. Chest wall

2. Pectoralis muscles

3. Lobules

4. Nipple

5. Areola

6. Milk duct

7. Fatty tissue

8. Skin

There is considerable variation in a the volume, shape, size and spacing of a woman's breasts. They vary in size, density, shape, sag and position on a woman's chest, and their external appearance is not predictive of their internal anatomy or potential for nursing. The three major determinants of breast appearance are size, shape of the individual

3 ------Review of Literature breast and the position of the breast and nipple when standing in an upright position. (Jelovsek, Frederick R,2011).

Normal life events that produce hormonal changes can alter the size and shape of a woman's breasts. These include the menstrual cycle, menopause, or medical conditionsincluding virginal breast hypertrophy. Women can experience unusual or unexpectedly rapid growth in breast size during pregnancy or after birth. (Wood K,et al,2008).

The natural shape of a woman's breasts is primarily dependent on the support provided by the Cooper's ligaments and the underlying chest on which they rest (the base). Cooper's ligaments, also known as the suspensory ligaments of Cooper, suspend the breasts from the clavicle and the clavi-pectoral fascia. As their fibers run around and through the breast, these ligaments support the breasts in its position on the chest wall and maintain their normal shape. The breast is also attached at its base to the chest wall by the deep fascia over the pectoral muscles. In a small number of women, the frontal ducts (ampullae) in the breasts are not flush with the surrounding breast tissue, which causes the sinus area to visibly bulge outward. (Last's Anatomy,2006).

The (or line, or crease) is an anatomic structure created by adherence between elements in the skin and underlying connective tissue and represents the inferior extent of breast anatomy. The relationship of the nipple position to the inframammary fold is described as ptosis.

Due to the natural weight of breasts, relaxation of support structures, and most of all aging, the nipple-areola complex and breast tissue may eventually hang below the fold, and in some cases depending on their size the breasts may extend as far as, or even beyond, the navel. The length from the nipple to the sternal notch (central, upper border) in

4 ------Review of Literature the youthful breast averages 21 cm and is a common anthropometric figure used to assess both breast symmetry and ptosis. Lengthening of both this measurement and the distance between the nipple and the fold are both characteristic of advancing grades of ptosis. (Plastic & Reconstructive Surgery of the Breast,2009).

The end of the breast, which includes the nipple, may either be flat (a 180° angle) or angled (angles lower than 180°). Breast ends are rarely angled sharper than 60°. Angling of the end of the breast is caused in part by the ligaments that suspend it, such that the breast ends often have a more obtuse angle when a woman is lying on her back. Breasts exist in a range of ratios between length and base diameter, usually ranging from ½ to 1 .(Bentley, Gillian R.,2001).

Up to 90 per cent of women's breasts are asymmetrical in size or position to some degree. Up to 25% of women's breasts display a persistent, visible breast asymmetry,which is defined as differing in size by at least one cup size. For about 5% to 10% women, their breasts are severely different, with the left breast being larger in 62% of cases. For these women, the asymmetry is sufficiently different that a surgeon would consider corrective surgery. Most surgeons will only perform an augmentation procedure to treat asymmetry if the woman's breasts differ by at least one cup size. The asymmetry may be reflected in the size of the breast, the positioning of the nipple on the breast, the angle of the breast, and the position or relative height of the inframammary fold where the breast begins on the woman's chest. (Anders Pape Moeller, et al.1995).

Why some women's breasts are asymmetrical is not well understood, although genetics are believed to be partly responsible. During puberty, the hormone oestrogen triggers the breast tissue growth,

5 ------Review of Literature usually beginning about two years after the girl's first menstrual period. Breast tissue continually grows for up to four years, during which there are naturally occurring size differences. Most women gain their final breast shape and size at about age 21. (Anders Pape Moeller, et al.1995).

As breasts are mostly composed of adipose tissue, their size can change over time. This occurs for a number of reasons, most obviously when a girl grows during puberty and when a woman becomes pregnant. The breast sizemay also change if she gains (or loses) weight for any other reason. Any rapid increase in size of the breasts can result in the appearance of stretch marks.

Fig. (2) (Introduction to the human body,2001).

It is typical for a number of other changes to occur during pregnancy: in addition to becoming larger, the breasts generally become firmer, mainly due to hypertrophy of the mammary gland in response to the hormone prolactin. The size of the may increase noticeably and their pigmentation may become darker. These changes may continue during . The breasts generally revert to approximately their

6 ------Review of Literature previous size after pregnancy, although there may be some increased sagging and stretchmarks. (Essentials of breast surgery,2009).

The size of a woman's breasts may fluctuate during the menstrual cycle, particularly with premenstrual water retention. An increase in breast size is a common side effect of use of the combined oral contraceptive pill.

Breasts sag if the ligaments become elongated, a natural process that can occur over time and is also influenced by the breast bouncing while exercising . Breasts can decrease in size at menopause if estrogen levels decline. (Bentley, Gillian R.,2001).

Development and structure of the breast:

The breast is a modified sweat gland and begins to develop as early as the fourth week as a downgrowth from a thickened mammary ridge (milk line) of along a line from the axilla to the inguinal region.

Supernumerary nipples or even glands proper may form at lower levels on this line. (Last's Anatomy,2006).

Lobule formation occurs only in the female breast and does so after puberty.Each is connected to a tree-like system of ducts and lobules,intermingled and enclosed by connentive tissue to form a lobe of the gland.The resting (non-lactating) breast consist mostly of fibrous and fatty tissue;variations in size are due to variations in fat content,not glandular tissue which is very sparse. (Last's Anatomy,2006).

The blood supply of the breast :

The blood supply to the breast skin depends on the subdermal plexus, which is in communication with deeper underlying vessels

7 ------Review of Literature supplying the breast parenchyma. The blood supply is derived from the following:

•The lateral thoracic artery mainly, by branches that curl around the border of pectoralis major and by other branches that pierce the muscle.

•The internal mammary perforators through the intercostal spaces behind the sternum. (most notably the second to fifth perforators).

•The thoracoacromial artery by its pectoral branches,supplying the upper part of the breast.

•The vessels to serratus anterior

•The terminal branches of the third to eighth intercostal perforators. (Last's Anatomy,2006)

The various supplying vessles form an anastomosing network.

Fig. (3) (Introduction to the human body,2001).

8 ------Review of Literature

The superomedial perforator supply from the internal mammary vessels is particularly robust and accounts for some 60% of the total breast blood supply. This rich blood supply allows for various reduction techniques, ensuring theviability of the skin flaps after surgery. (Essentials of breast surgery,2009)

From a circumareolar venous plexus and from glandular tissue venous drainage is mainly by deep veins that run with the main arteries to internal thoracic and axillary veins.Some drainage to posterior intercostal veins provides an important link to the internal vertebral venous plexus veins and hence a pathway for metastatic spread to bone.(Last's Anatomy,2006)

Blood is drained away from the breasts by these veins leading to the superior vena cava which enters the right side of the heart .

Lymphatic drainage of the breast:

Lymph is a clear fluid that travels through the breast carrying away waste from the breast to the lymph nodes where bacteria and other foreign particles are filtered out. From there lymph is transported into the axillary lymph vessels and the nodes under the armpits.

Fig. (4) (Introduction to the human body,2001).

9 ------Review of Literature

Lymphatics of the breast communicate with a subareolar plexus of lymphatics.About 75% of lymph from the breast travels to the ipsilateral axillary lymph nodes(mainly to the anterior nodes,some to the posterior nodes;direct drainage to central or apical nodes is possible).The rest travels to parasternal nodes along theinternal thoracic artery, to the other breast, or abdominal lymph nodes.

The axillary nodes vary from twenty to thirty in number, and may be arranged in the following groups: the pectoral (or anterior), subscapular (or posterior), humeral(or lateral),central,infraclavicular and apical groups of lymph nodes:

Fig. (5) (Introduction to the human body,2001).

10 ------Review of Literature

Anterior nodes:

The anterior nodes (pectoral nodes, medial nodes; sometimes inferior nodes) are four to five nodes lying along the inferolateral border of pectoralis major, related to the lateral thoracic artery. Afferents drain the skin and muscle of the anterolateral thoracic wall, as well as the central and lateral breast. Efferents pass to the central and apical nodes .

Posterior nodes:

The posterior nodes (subscapular nodes, inferior nodes) are six or seven nodes on the lower margin of the posterior wall of the axilla, along the course of the subscapular artery. Its afferents drain the skin and muscle of the posterior thoracic wall as wellas the lower posterior neck. Its efferents pass to the central nodes.

Infraclavicular nodes:

The infraclavicular nodes (subclavicular nodes) are two or three nodes situated superiorly and posteriorly to the axillary artery, inferior to the clavicle. They receive lymph from the superficial vessels around the cephalic vein. Their efferents drain directly into the apical nodes, to which they are closely associated .

Central nodes:

The central nodes (intermediate nodes)are a group of three or four nodes in the adipose tissue at the base of the axilla. Its afferents are from the lateral, anterior and posterior nodes; its efferents drain into the apical nodes.

11 ------Review of Literature

Apical nodes:

The apical nodes are a group of five to ten glands, partly posterior and partly superior to pectoralis minor. It has afferents from the superior breast and mammary tail, as well as receiving afferents from all other groups of the axilla. Its efferent vessels unite to form the subclavian lymph trunk .

Lateral nodes:

The lateral nodes are a group of four to six nodes, lying medial and posterior to the axillary vein along the lateral wall of the axilla. Afferent vessels to these nodes drain the upper limb, excepting the superficial vessels around the cephalic vein. Its efferent vessels drain to the infraclavicular nodes, apical nodes and central nodes of the axilla as well as the inferior deep cervical lymph nodes. ( Ramsay DT et al,2005).

Fig. (6) (Gray's Anatomy of the human body,1918)

12